At the age of 25, I discovered that my breasts may pose a significant health risk. A close family member tested positive for the BRCA1 genetic mutation, which is associated with an increased chance of developing breast cancer. This news prompted our entire family of women to undergo testing as soon as possible. Unfortunately, I too tested positive, meaning I faced a 72% likelihood of developing breast cancer at some point in my life.
Prior to this diagnosis, I had always believed that illness and death were things that happened to other people. I was young and fortunate to be in good health. The BRCA1 diagnosis forced me to confront my mortality and make difficult decisions. I could choose to ignore the risks and hope for the best, but the statistics were against me. Alternatively, I could opt for regular screenings such as mammograms and sonograms to detect any potential cancer early. However, the most effective form of protection would be prophylactic surgery.
For quite some time, I couldn’t bring myself to take any action. Even as more family members tested positive, I avoided discussing the topic during family gatherings. It wasn’t until two years after my diagnosis that I felt strong enough to reach out to a genetic counselor who then referred me to a surgical oncologist. In my first meeting with the surgeon, she matter-of-factly stated that the safest course of action would be a double mastectomy, ideally by the age of 35. I was taken aback by the short timeline and had a strong aversion to the idea of surgery. In the months following that appointment, I couldn’t help but think that I would rather die than lose my breasts.
However, at 33, I became a mother to my son. The changes my body went through during pregnancy and breastfeeding made the idea of further physical change less daunting. Above all, becoming a mother made staying alive my top priority. By opting for the surgery, my risk of breast cancer would decrease to less than 1%. Throughout her career, my surgical oncologist had never encountered a case of breast cancer in any of the hundreds of patients she had performed the same surgery on. After receiving another clear mammogram in April, I decided that I no longer wanted to live under the constant threat of breast cancer and sought advice from a plastic surgeon.
Interestingly, the plastic surgeon’s first question wasn’t about what I wanted to do, but rather about how I was feeling emotionally. This opened up a space for me to express the fear, sadness, anxiety, and anticipation of grief and loss that I had been carrying for so long. The plastic surgeon and his nurse practitioner addressed my emotions before discussing my physical options or potential procedures. In a time where medical encounters are often rushed and last only 15 minutes, this hour-long conversation, filled with silence, tears, and questions, felt like a small miracle.
When the discussion finally turned to surgical options, we explored whether I wanted to undergo breast reconstruction surgery or choose to “go flat” without implants. I was surprised by the intensity of my emotions. While breasts do not define a woman, they are an integral part of how I understand and experience my own gender identity. They not only hold notions of beauty but also represent the physical connection I had with my son during breastfeeding. I couldn’t envision feeling truly comfortable and confident in my body without them. I am privileged to have always felt aligned with the gender I was assigned at birth, but I now realize how deeply attached I am to my gender identity and how uncomfortable I would feel if my body didn’t align with that perception. This led me to understand that the term “gender-affirming care” applies to cis women like me. Gender-affirming care typically refers to healthcare services that validate a person’s gender identity when it clashes with the gender assigned at birth. However, cis individuals also benefit from medical interventions that affirm their gender identity. In America alone, over 300,000 breast augmentations are performed annually. And this is just one example of countless aesthetic surgeries and procedures aimed at helping cis women enhance or create “feminine” attributes. Similarly, some cis men undergo hair transplants, take steroids to increase muscle mass, or use Viagra to maintain their “masculine” virility. Trans individuals are not the only ones seeking medical care that affirms their gender, but they face different challenges when accessing it.
Implants do not reduce the risk of cancer and can carry potential risks such as infections and complications. Yet, breast reconstruction for cis women is considered a “medical necessity,” allowing insurance companies to cover procedures costing tens of thousands of dollars. If the criteria for medical necessity were purely focused on preventing illness and death, implants wouldn’t be eligible. However, living is not just about avoiding death.
When my surgeries were submitted for pre-authorization, they were quickly approved without any conversations where I had to justify my decision. I never had to go through the trauma of being denied. In contrast, trans individuals seeking gender-affirming surgeries often face significant institutional barriers when accessing care. While some insurance companies recognize the scientific evidence supporting the health benefits of gender-affirming surgeries, not all do. Even when insurers cover gender-affirming care, navigating through complex bureaucratic processes and appealing denials can be challenging. Sometimes, third-party validation from psychologists is required to deem a trans person mentally sound and deserving of the care they want. All of this occurs amidst a backdrop of hostility toward gender-affirming healthcare for trans Americans. State legislators across the country are actively undermining the rights of individuals to make their own medical decisions, callously endangering lives due to their own fear, ignorance, and bigotry. Recently, Louisiana passed legislation that bars anyone under the age of 18 from receiving gender-affirming surgeries, puberty-blocking medications, or hormone treatments.
These disparities can have severe consequences for the health of trans individuals. Research consistently shows higher rates of depression, anxiety, and suicidal tendencies among trans people. Gender-affirming surgeries have been proven to significantly improve the health outcomes of those who undergo them. The fact that my mastectomy and elective breast implants are applauded as “brave” while trans individuals seeking gender-affirming care are scrutinized, shamed, and even criminalized is not only nonsensical but also immoral.
I am not excited about undergoing surgery. I fear the pain and discomfort and feel saddened to bid farewell to a version of my body that I have cherished and that has been cherished by others. However, I am confident that my community will support me and help me through this challenging time, and this level of support should be available to everyone.
When I informed my oncologist in April that I was ready to proceed with the surgery after nearly a decade of her care, she broke into a wide, radiant smile. Confused, I asked her why she was so happy. Her response was, “Now, I don’t have to worry about you!” She truly valued my life and took joy in being part of preserving it. All patients, regardless of their gender identity, deserve to experience that feeling.
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